Chapter 10: MAternal Child
FHR baseline at 150 bpm
A client in active labor has an external fetal monitor in place. Using the monitor strip below, identify the correct assessment.
Below the umbilicus on the right side
After performing Leopold maneuvers on a laboring client, a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler be placed to best auscultate fetal heart tones?
Monitor the FHR until it returns to baseline when the contraction ends
An external monitor is placed on the abdomen of a client admitted in active labor. The nurse identifies that during each contraction, the FHR decelerates as the contraction peaks. What should the nurse do next?
The most comfortable position can be assumed.
An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while the monitor is in place?
Returns to baseline HR after a contraction ends
During labor, a client has an internal fetal monitor applied. What FHR should most concern the nurse?
100 t0 120
During labor, a nurse identified that there is an early FHR deceleration. Who many fetal heartbeats per minute were there early in the contraction that indicated to the nurse that the deceleration occurred?
Intrusion on movement
What is a common problem that confronts the client in labor when an external fetal monitor has been applied to her abdomen?
The machinery may be frightening to a laboring couple
A 36 year old primigravida, accompanied by her husband, is admitted to the birthing unit at 39 weeks' gestation. External fetal monitoring is instituted. What should the nurse consider when a fetus is being monitor?
Notify the health care provider
A client in labor begins to experience contractions 2-3 minutes apart that last about 45 seconds. Between contractions the nurse identifies a fetal heart rate of 100 bpm on the internal fetal monitor. What is the next nursing action?
Auscultating the fetal heart
A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process?
Change the client's position
A clients membranes rupture while her labor is being augmented with an oxytocin infusion. A nurse observes variable deceleration in the FHR on the fetal monitor strip. What action should the nurse take next?
abrupt decreases in FHR that are unrelated to the contractions
A nurse is observing a reading on the external fetal monitor of a client in active labor. Which fetal heart pattern indicated cord compression?
uteroplacental insufficiency
At 38 weeks' gestation, a client is admitted to the birthing unit in active labor and an external fetal monitor is applied. Late FHR deceleration begin to appear when her cervix is dilated 6 cm, with every contraction occurring every 4 minutes ans lasting 45 seconds. What does the nurse conclude is the cause of these late deceleration's?
an acceleration
When monitoring the FHR of a client in labor, the nurse identified an elevation of 15 beats more than the baseline rate of 135 bpm lasting for 15 seconds. How should the nurse document this event?
